Abstract Introduction Concurrent pulmonary embolism (PE) and arterial thrombosis are exceedingly rare, and there is limited literature guiding their clinical management. In the absence of a shunt, the simultaneous occurrence of saddle PE and superior mesenteric artery (SMA) thrombosis is typically attributed to an underlying severe hypercoagulable state. Given the high risk of morbidity and mortality associated with each condition, timely recognition and coordinated intervention are critical to improving patient outcomes. Description A 55-year-old male with no significant medical history presented with a 3-week history of intermittent angina and dyspnea, followed by acute-onset severe abdominal pain and hematochezia. He appeared distressed, writhing in pain, tachypneic, symmetric pulses, with soft but tender abdomen. Initial labs showed lactic acidosis (4.8 mmol/L), slightly elevated WBC count 11.6 × 10³/μL with neutrophilic predominance, otherwise unremarkable renal/liver function test, electrolytes, lipase, urinalysis and toxicology screen. Urgent CTA of the chest, abdomen, and pelvis revealed a saddle pulmonary embolism extending into bilateral segmental branches with right heart strain (RV/LV ratio 1.5). Imaging also demonstrated diffuse thrombus with complete occlusion of the SMA, concerning for acute mesenteric ischemia. Troponin I was elevated at 637 ng/L, and EKG showed anteroseptal T-wave inversions with right axis deviation. Urgent echocardiography showed no intracardiac thrombus or interatrial shunting. Heparin drip was initiated, and general surgery, vascular surgery, and interventional radiology were consulted for combined intervention. The patient was immediately sent to OR where an aortogram with mesenteric angiogram was performed; the SMA stump was cannulated and alteplase administered. Unfortunately, during the procedure, the patient acutely decompensated, developing a tachyarrhythmia requiring immediate cardioversion, lost pulses, underwent ACLS, and achieved ROSC. VA-ECMO was initiated. Due to his unstable condition, thrombectomy of the pulmonary arteries was deferred. On stabilization, emergent laparotomy revealed diffuse ischemia and full-thickness necrosis of the entire small bowel, findings deemed incompatible with life. Prognosis was poor, and care was withdrawn after discussion with the family. Discussion This case highlights the critical importance of early recognition and aggressive, multidisciplinary management of simultaneous arterial and venous thromboembolic events. Even in patients without previously identified risk factors, such as cardiac shunts or known hypercoagulable states, the occurrence of combined thrombotic pathologies demands rapid diagnostic workup and prompt intervention to prevent catastrophic outcomes. Our report emphasizes the need for increased clinical awareness and further research into the optimal treatment strategies for these rare but devastating presentations. This abstract is funded by: None
Garcia et al. (Fri,) studied this question.
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